For out-of-the box thinking on improving care while saving money, you might think to call health-care delivery experts from a top medical school. But when Arnold Milstein, MD, who leads Stanford's Clinical Excellence Research Center, decided to try to shave costs from Stanford's own health insurance plan, he turned to a region better known for its marijuana than for its health care expertise: Humboldt County.
Hilly and forested, this rural region north of the Bay Area just happened to be home to Alan Glaseroff, MD, and his wife Ann Lindsay, MD. The tale of how they, and Milstein, created a clinic called Stanford Coordinated Care for patients with multiple, complex conditions appears in the current issue of Washington Monthly.
This wasn't just any clinic. Its goal was to care for the 5 percent of patients who account for 50 percent of health care costs, according to Milstein. To do that effectively, the traditional fee-for-service model, which pays physicians only for procedures and office visits, had to go.
The article explains:
To figure out how to improve care for the most fragile patients, Lindsay and Glaseroff analyzed the records of the biggest regular health care users among Stanford employees and their dependents, looking for conditions shared by multiple patients. The goal, said Glaseroff, was to build a team that could meet the most common needs. That way, they wouldn't have to refer to specialists outside of the clinic. Fewer referrals meant fewer additional charges to Stanford Health Care -- the university's self-funded health insurance system -- and fewer copays for patients. The intensive care would also, theoretically, help patients avoid health crises that often sent them to the emergency room.
The final team was small but powerful: two physicians... a registered nurse, a physical therapist, a social worker, a pharmacist, and four medical assistants who would be trained to act as 'care coordinators.'
This team would spend two hours -- yes, two entire hours -- with new patients. Follow-up appointments were slated for one hour, including half an hour with a physician. Between appointments, patients could connect with their doctors or coordinators via phone or email.
Team meetings -- to divvy up work and discuss complex cases -- are regular, a departure from traditional models where physicians only rely on what is written in a patient's chart.
The goal is to empower patients, team members say in the article. They try to instill hope and motivation and provide support as needed, like when a patient is tempted to visit the emergency room.
This approach worked, team members found. Discounting one very expensive heart transplant patient, caring for 253 patients in the first six months of operation of Stanford Coordinated Care saved 13 percent of costs as compared to the previous six months.
This success was noticed in Washington, D.C. A new federal rule for medically fragile patients was partially based on the Stanford model, the article states. Yet with the future of federal health care policy in limbo, the further spread of this experiment remains unknown.
As for Glaseroff and Lindsay? They're headed back to Humboldt County, "which Lindsay missed every day of the five years they spent" here, with Glaseroff planning to commute to Stanford.
Previously: Stanford Coordinated Care: A team approach to taming chronic illness and Improving care for the frailest, elderly patients
Photo of Glaseroff and Lindsay in 2014 by Norbert von der Groeben